The stories have gone from medicine and that’s a shame

I was at a dinner meeting for our hospital last week, and before everyone went in to sit at their tables and hear the evenings’ speeches, there was some time for the usual networking over wine in the reception room. I got chatting to an established local primary care physician, a respected member of the hospital staff who has been in practice for over 30 years.

He’s quite a presence and a great clinician, someone who still finds himself coming into the hospital to work on various administrative duties. I expect every hospital in the country has characters like him wandering around. We got chatting about all the changes that have occurred in medicine over the last few decades since he first graduated, and the conversation quickly turned to his dislike of the current information technology systems (the IT crowd, unfortunately, tend to live in a bubble of the “wonderful world of connectivity, big data, and cloud solutions” — but this conversation could have happened anywhere in America).

During our discussion — as we commiserated about how physicians and nurses are glued to their computer screens nowadays, clicking boxes, and typing away furiously on their keyboards — he said something that struck a chord. He said, “You know what Suneel, the stories have really gone from medicine.”

What did he mean by this? He elaborated, and we continued talking. In a nutshell, what he meant was that in the past, every patient was a story. A unique person. A human being. This patient was well known to their personal physician, whom they usually had a good and strong relationship with. Even when documenting information in a hospital, when a physician saw a patient (regardless of whether that physician already knew the patient), there would be a story that would appear on the computer or in the chart in the form of a transcribed letter. This was either a history and physical report or a discharge summary. It would take the form of a narrative, in proper English with logical paragraphs and sentence construction, and tell you all about what was wrong with the patient, their individual history, and the diagnosis and treatment plan.

Unfortunately, what has occurred over the last few years has been quite the opposite. If you look at these narratives as they appear in the world of health care IT, they have developed into reams of computer gabble. A patient’s story is now a series of tick boxes, random meaningless data, and ill-thought-out information flow — difficult to read and decipher. Glance at a printout of this, and they are no better than a typical handout you would get from a car dealership after your car has been serviced. Far inferior to the good old-fashioned transcribed letters that would tell you what happened to a patient in a more proper format. Worse still, many office-based interactions with physicians are now reduced to screen staring and mouse clicking, as the patient’s story gets told in a row of tick boxes.

While nobody wants to go back to the days of paper charts, we must do better than this. Doctors are intelligent people, and the computer output that results from our most important interactions needs to return to a well-designed and more logical narrative.

The physician that I had this conversation with likely only has a few years left till retirement. I’m glad many of his generation are still here to give us their perspective of the changes we’ve seen occur in the practice of medicine. As for his patients, many of whom I’ve taken care of, they are still very much in awe of a doctor who knows how it’s done. A doctor who listens to them, talks to them face-to-face, and keeps his clinical reasoning skills. And one who ultimately understands that health care is all about real people who are all their own stories.

Physician Coaching by KevinMD

The stories have gone from medicine and that’s a shame 14 comments

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southerndoc1

“While nobody wants to go back to the days of paper charts”

Putting that in very post doesn’t make it true.

Recently saw my dermatologist. His new associate just left her dream job at a top 5 academic institution down the road specifically to get away from the EHR that demanded 90 minutes of data input every night. Now she’s using paper, gets home to family by 5:30, and is much happier. If EHRs don’t work for derms . . .

There are many, many docs who are finally willing to admit that we lost much more than we gained in going from paper to digital.

Dr. Drake Ramoray

“If EHRs don’t work for derms……”

Isn’t that the truth.

The best neurosurgeon in my state if not a large region of the country is retiring about 10 years early. Reason. Government mandates, red tape, EHR.

Sigh.

NewMexicoRam

I wish I could go back to paper charts.
I used to go home at 5:30 also. Until……..

Patient Kit

My sister works for HHC, NYC’s public hospital system and, I think, the biggest public hospital system in the country. She’s an outpatient psychotherapist (MSW not MD) and they still use paper charts for all mental health patients. The medical clinicians use an EHR. but not the mental health clinicians. I wonder if that’s common or unusual in 2016. I wonder why they don’t have to use an EHR.

southerndoc1

Practicing in a high tech area, we’ve found our paper charts to be a tremendous draw for new patients.

Ladyimacbeth

I believe it. Given the choice I would definitely choose a physician with a paper chart over one who has an EMR.

meyati

I was unhappy with the lack of communication between the ER and Primary in my current network of 6 years. The patient had more control of the health history. At least I tore out pages that I didn’t like. I’m 74, and my meds are Zantac, Flonase, Armour thyroid. My labs are good, my heart, BP, lungs, kidneys, liver, bones, mind, and teeth are excellent. I had high BP for about 6 years, and it finally went down when I ran into a physician that reduced my thyroid hormone suppliment. I am stuck with that dx. The problem is more than EHRs, it’s also the speed dating, and rigid protocols.

Ladyimacbeth

Sounds like those psychiatrists and therapists stood up for their patients. Good for them.

The EMR issues was one of the reasons I wrote my own. I want a narrative that tells the story the same way that the time tested H&P did from the moment I learned it in medical school.

The sad thing is that even when I create these well written documents, and send them with patients to one of the CHOA ERs because I think they may need to be admitted, no one ever reads them.

The tiger is, after all, an endangered species, isn’t it.

Warmest regards,

Ron Smith, MD
Pediatrics
McDonough, Georgia

Buddha

They told the tiger. “Let us play a game and we need you to put your skin in the game” and the tiger was skinned alive. Now tiger had no skin and hence no stripes. Then everybody looked at the creature and said. “Look this is no tiger it has no stripes”. Then everybody thought that this animal which they had never seen, must be burden of beast. They loaded their bountiful munificence of certificate of medical necessities for all the things that made up their healthcare one by one on to the back of the tiger. The paper stuck to the flayed skin of the tiger and it looked like a strange animal. There were papers everywhere flying around and new name for the animal was paper donkey.
Then there was a single “pear” who insisted that everything else is an onion and he alone is a pear. To prove he said let us peel the paper donkey and you can see layers coming off. So they peeled the paper donkey and found that every time they peeled a paper, more paper appeared. So they got convinced that tiger was not a paper donkey but actually an onion, something they did not like.
So they said we do not want onions, we want pear and that too a single pear! They shouted look I am not greedy I do not want onion I want a single pear.
Then they found a single pear and crowned him king of the jungle. That was the “change” everyone wanted but never got in two terms cause they were told “If you like your tiger you can keep it” Now everyone thought that had one pear. Since pear was single it was rationed and pictures of the pear got passed around. These pictures were called Pear Care Pretender (PCP).
Everyone said, look this is a Norwegian Single Pear. It was funny though because the Norwegian Single Pear always smelled of oil. The oil of North Sea! And they did not know nothing about North Sea oil and hence did not ask questions!
They said new motto now is “if you like it you can smell it” and the smell was “bern”ing.!!

PW

It’s not about the “patient” anymore. It’s about the wicked beast EMR who has to be fed with precise information, otherwise the hapless physician or health care institution will not get paid. If the feedings continue to be incorrect, the “providers” risk being eaten alive by the system.
Meanwhile the luckless patient, Mr. or Mrs. Smith is just a meaningless diversion who threatens to keep the “provider’s” attention off the beast. They too, will be devoured eventually.

Buddha

And the pear says ..”Yum. .. my meal!!”

Gerry Creager

So we had the onset of electronic medical records probably 15 years ago, in earnest. And precious few clinicians would look at them. I, not a clinician, but a researcher with a bit of clinical background long, long ago, got roped into helping with an open-source version that can at least create output that could be read by the major, for-profit EMRs. What emerged, when there was, indeed, a mandate, was a Tower of Babble. Most on’t really talk to each other, lots of paper is being generated. Too many check boxes, and as my internest says, “I hope you don’t mind getting cheek-time instead of face-time…”

There are alternatives out there, but what must happen is that the bean counters at the hospitals and clinics need to understand that what they’ve mandated, with the help of their IT gurus (who, almost certainly, have never done an H&P in their lives) that the clinicians use the system these bureaucrats think is the “best” but they’re not thinking about the needs of the patients, or the care they’re forcing their clinicians to skip, to fill all the check boxes.

If we really need another mandate, it should start with requiring all the for-profit EMRs to be interoperable with all others, and to support strong encryption and security. They should allow the clinician to determine whether they’ll use check-boxes and checklists, or more lengthy narratives to get all the details in place. They’ll develope an artifial intelligence system that will mine the chart, as presented, to get the summaries and coding necessary to satisfy “the system”. They’ll be simple enough to use, and tested with the people who will use ’em (as opposed to training the clinicians, and telling them that’s what their choice is) for utility, and iterated ’til they are usable.

I am confident that, while it’d take a complete rewrite of most, or all of the commercially available EMRs out there, this is achievable, and actually one of the best approaches. But the answer is not now, and never should have been, to force clinicians to use an EMR just for the sake of using an EMR.

Jeff Kane

EHRs aid the science of medicine, but savage its art. Medicine’s art can’t possibly be digitized because human beings are analog entities. The time and attention EHRs require displace the physician’s necessary attention to feeling and nuance. The artful practitioner knows how to act therapeutically with patients, feels confident making medicine’s many subjective decisions, and is as attuned to intuition as to facts. If we persist in digitizing healthcare, we’ll eventually replaced by vending machines.
Jeff Kane MD
HealingHealthcareBook.com/category/healthcare-as-though-people-matter/